Coma

PROLOGUE, February 14, 1976

Nancy Greenly lay on the operating table on her back, staring up at the large kettledrum-shaped lights in operating room No. 8, trying to be calm. She had had several pre-op injections, which she was told would make her sleepy and happy. She was neither. Nancy was more nervous and apprehensive than before the shots. Worst of all, she felt totally, completely, and absolutely defenseless. In all her twenty-three years, she had never before felt so embarrassed and so vulnerable. Covering her was a white linen bed sheet The edge was frayed, and there was a small tear at the corner. That bothered her, and she didn’t know why. Under the sheet, she had on one of those hospital gowns which tie behind the neck and descend only to mid-thigh. The back was open. Other than that, there was only the sanitary napkin, which she knew was already soaked with her own blood. She hated and feared the hospital at that moment and wanted to scream, to run out of the room and down the corridor. But she didn’t. She feared the bleeding that she had been experiencing more than the cruel detached environment of the hospital; both made her acutely aware of her mortality, and that was something she rarely liked to face.

At 7:11 on the morning of February 14, 1976, the eastern sky over Boston was a chalky gray, and the bumper-to-bumper cars coming into the city had their headlights on. The temperature was thirty-eight degrees, and the people in the streets walked quickly on their separate tracks. There were no voices, just the sound of the machines and the wind.

Within the Boston Memorial Hospital, things were different. The stark fluorescent lights illuminated every square inch of the OR area. The bustle of activity and excited voices lent credence to the dictum that surgery started at 7:30 sharp. That meant the scalpels actually cut the skin at 7:30; the patient fetching, the prep, the scrub, and the induction under anesthesia had to be all completed before 7:30.

As a consequence, at 7:11, the activity in the OR area was in full swing, including room number 8. There was nothing special about No. 8. It was a typical OR in the Memorial. The walls were a neutral-colored tile; the floors were a speckled vinyl. At 7:30, February 14, 1976, a D&C—dilation and curettage, a routine gynecological procedure—was scheduled in room No. 8. The patient was Nancy Greenly; the anesthesiologist was Dr. Robert Billing, a second-year anesthesiology resident; the scrub nurse was Ruth Jenkins; the circulating nurse was Gloria D’Mateo. The surgeon was George Major—the new, young partner of one of the older, established OB-GYN men—and he was in the dressing room donning his surgical scrub suit, while the others were hard at work.

Nancy Greenly had been bleeding for eleven days. At first she passed it off as a normal period, despite the fact that it was several weeks early. There had been no premenstrual discomfort, maybe a vague cramp on the morning the first spotting occurred. But after that it had been a painless affair, waxing and waning. Each night she hoped to have seen the last of it but had awakened to find the tampon soaked. The telephone conversations, first with Dr. Major’s nurse, then with the doctor himself, had allayed her fears for progressively shorter and shorter durations. And it was a bother, a gigantic nuisance, and as it was with such things, it had come at a most inopportune time. She thought about Kim Devereau coming up to spend his spring break from Duke Law School with her in Boston. Her roommate had fortuitously made plans to spend that week skiing at Killington. Everything seemed to have been falling into beautiful, romantic place, everything except the bleeding. There was no way Nancy could blithely dismiss it. She was a delicately angular and attractive girl with an aristocratic appearance. About her person she was fastidious. If her hair was the slightest bit dirty she felt uneasy. So the continued bleeding made her feel messy, unattractive, out of control. Eventually it began to frighten her.

Nancy remembered lying on the couch with her feet up on the arm, reading the editorial page of the Globe while Kim was in the kitchen making drinks. She had become aware of a strange sensation in her vagina. It was different from anything she had ever felt before. It felt as if she was being inflated by a warm soft mass. There had been absolutely no pain or discomfort. At first she was perplexed as to the origin of the sensation, but then she felt a warmth on her inner thighs and a tickling trickle of fluid run down into the recess of her buttocks. Without undue anxiety, she recognized that she was bleeding, bleeding very fast. Casually, without moving her body, she had turned her head toward the kitchen and called out, “Kim, would you do me a favor and call an ambulance?”

“What’s wrong?” asked Kim, hurrying to her.

“I’m bleeding very fast,” said Nancy calmly, “but it’s nothing to get alarmed about. An extra-heavy period, I guess. I just should go to the hospital right away. So please call the ambulance.”

The ambulance ride had been uneventful, without sirens or drama. She had to wait longer than she thought reasonable in the holding area of the emergency room. Dr. Major had appeared and for the first time awakened a feeling of gladness in Nancy. She had always detested the routine vaginal exams to which she had submitted and has associated the face, the bearing, and the smell of Dr. Major with them. But when he appeared in the emergency room, she felt glad to see him, to the point of suppressing tears.

The vaginal examination in the emergency room had been, without doubt, the worst she had ever experienced. A flimsy curtain, which was constantly being whisked back and forth, was the sole barrier between the throng in the emergency room and Nancy’s flayed self-respect. Blood pressure was taken every few minutes; blood was drawn; she had to change from her clothes into the hospital gown; and each time something was done the curtain flashed aside and Nancy was confronted with an array of faces in white clothes, children with cuts, and old, tired people. And there was the bedpan sitting there right in the open for everyone to gape at. It contained a large, semiformed dark red blood clot. Meanwhile Dr. Major was down there between her legs touching her and talking to the nurse about another case. Nancy closed her eyes as tightly as she could and cried silently.

But it was all to be over shortly, or so Dr. Major had promised. In great detail he had told Nancy about the lining of her uterus and how it changes during the normal cycle and what happens when it doesn’t change. There was something about the blood vessels and the need for an egg to be released from the ovary. The definitive cure was a dilation and curettage. Nancy had agreed without question and asked that her parents not be notified. She could do that herself after the fact. She was sure her mother would think she had had to have an abortion.

Now, as Nancy gazed up at the large overhead operating room light, the only thought that made her the slightest bit happy was the fact that the whole goddamned nightmare was going to be over within the hour, and her life would return to normal. The activity in the operating room was so totally foreign to her that she avoided looking at anyone or anything, save for the light above.

“Are you comfortable?”

Nancy glanced to the right. Deep brown eyes regarded her from between the synthetic fibers of the surgical hood. Gloria D’Mateo was folding the draw sheet around Nancy’s right arm, securing it to her side and immobilizing her further.

“Yes,” answered Nancy with a certain detachment. Actually she was as uncomfortable as hell. The operating table was as hard as her cheap Formica kitchen table. But the Phenergan and Demerol she had been given were beginning to exert their effects somewhere within the depths of her cerebrum. Nancy was far more awake than she would have liked; but at the same time she was beginning to feel a detachment and dissociation from her surroundings. The atrophine she had been given was having an effect as well, making her throat and mouth feel dry and her tongue sticky.

Dr. Robert Billing was engrossed with his machine. It was a tangle of stainless steel, upright manometers, and a few colorful cylinders of compressed gas. A brown bottle of halothane stood on top of the machine. On the label was written: “2-bromo-2-chloro-1,1,1-tri-fluoroethane (C2HBrClF3).” An almost perfect anesthetic agent. “Almost” because every so often it seemed to destroy the patient’s liver. But that rarely happened, and halothane’s other characteristics far overshadowed the potential for liver damage. Dr. Billing was crazy about the stuff. Somewhere in his imagination he pictured himself developing halothane, introducing it to the medical community in the lead article of the New England Journal of Medicine, and then walking up to receive his Nobel prize in the same tuxedo he had worn when he was married.

Dr. Billing was a damned good anesthesiology resident, and he knew it. In fact, he thought most everyone knew it. He was convinced he knew as much anesthesiology as most of the attendings, more than some. And he was careful, very careful. He had had no serious complications as a resident, and that was indeed rare.

Like a 747 pilot, he had made himself a checklist, and religiously he adhered to a policy of checking off each step of the induction procedure. This meant having Xeroxed off a thousand of the checklists and bringing a copy along with the other equipment at the start of each operation. By 7:15, the anesthesiologist was right on schedule at step number 12: that meant hooking up the rubber scubalike tubing to the machine. One end went into the ventilating bag, whose four-to five-liter capacity afforded him an opportunity to inflate forcibly the patient’s lungs at any time during the procedure. The other end went to the soda-lime canister in which the patient’s expired carbon dioxide would be absorbed. Step number 13 on his list was to make sure the unidirectional check valves in the breathing lines were lined up in the right direction. Step number 14 was to connect the anesthesia machine to the compressed air, nitrous oxide, and oxygen sources on the wall of the OR room. The anesthesia machine had emergency oxygen cylinders hanging from the side, and Dr. Billing checked the gauge pressures on both cylinders. They were fully charged. Dr. Billing felt fine.

“I’m going to place some electrodes on your chest so we can monitor your heart,” said Gloria D’Mateo while pulling down the sheet and pulling up the hospital gown, exposing Nancy’s midriff to the sterile air. The gown just barely covered Nancy’s nipples. “This will feel cold for a sec,” added Gloria D’Mateo as she squeezed a bit of colorless jelly onto three locations on Nancy’s exposed lower chest.

Nancy wanted to say something, but she couldn’t deal rapidly enough with her ambivalent attitudes about what she was experiencing. She was grateful, because it was going to help her, or so she had been assured; she was furious because she felt so exposed, literally and figuratively.

“You’re going to feel a little stick now,” said Dr. Billing, slapping the back of Nancy’s left hand to make the veins stand out. He had placed a piece of rubber tubing tightly around Nancy’s wrist, and she could feel her heart beat in the tips of her fingers. It was all happening too fast for Nancy to assimilate.

“Good morning, Miss Greenly,” said an ebullient Dr. Major as he whisked through the OR door. “I hope you had a good night’s sleep. We’ll get this affair over with in a few minutes and have you back to your bed for a restful sleep.”

Before Nancy could respond, the nerves from the tissues on the back of her hand became alive with urgent messages for her pain center. After the initial thrust, the intensity of the pain increased to a point and then dissipated. The snug rubber tourniquet disappeared, and blood surged into Nancy’s hand. She felt tears well up from within her head.

“I.V.,” said Dr. Billing to no one, as he made a black check next to number 16 on his list.

“You’ll be going to sleep shortly, Nancy,” continued Dr. Major. “Isn’t that right, Dr. Billing? Nancy, you’re a lucky girl today. Dr. Billing is number one.” Dr. Major called all his patients girls no matter what age they were. It was one of those condescending mannerisms he had adopted unquestioningly from his older partner.

“That’s correct,” said Dr. Billing, placing a rubber face mask on the anesthesia tubing. “Number eight tube, Gloria, please. And you, Dr. Major, can scrub; we’ll be ready at seven-thirty sharp.”

“OK,” said Dr. Major, heading for the door. Pausing, he turned to Ruth Jenkins, who was setting up the Mayo stand with instruments. “I want my own dilators and curettes, Ruth. Last time you gave me that medieval rubbish that belongs to the house.” He was gone before the nurse could answer.

Somewhere behind her, Nancy could hear the sonarlike beep of the cardiac monitor. It was her own heart rhythm resounding in the room.

“All right, Nancy,” said Gloria. “I want you to slide down the table a bit and put your legs up here in the stirrups.” Gloria grasped Nancy’s legs in turn under the knees and lifted them up into the stainless steel stirrups. The sheet slid between Nancy’s legs, exposing them from mid-thigh down. The lower part of the table fell away, and the sheet slid to the floor. Nancy closed her eyes and tried not to picture herself spread-eagled on the table. Gloria picked up the sheet and haphazardly put it on Nancy’s abdomen so that it draped between her legs, covering her bloodied and recently shaved perineum.

Nancy wanted to be calm, but she was getting more and more anxious. She wanted to be grateful, but the tide was swinging more and more in the direction of undirected anger and emotion.

“I’m not sure I want to go through with this,” said Nancy, looking at Dr. Billing.

“Everything is just fine,” said Dr. Billing in an artificially concerned tone of voice, while checking off number 18 on his list. “You’ll be asleep in a jiffy,” he added, while holding up a syringe and tapping it so that the bubbles all fled upward to the room air. “I’m going to give you some Pentothal right away. Don’t you feel sleepy now?”

“No,” said Nancy.

“Well, you should have told me,” said Dr. Billing.

“I don’t know how I’m supposed to feel,” returned Nancy.

“It’s all right now,” said Dr. Billing, pulling his anesthesia machine close to Nancy’s head. With well-rehearsed adeptness, he attached his Pentothal syringe to the three-way valve on the I.V. line. “Now I want you to count to fifty for me, Nancy.” He expected that Nancy would never get past fifteen. In fact, it gave Dr. Billing a certain sense of satisfaction to watch the patient go to sleep. It represented repetitive proof for him of the validity of the scientific method. Besides, it made him feel powerful; it was as if he had command of the patient’s brain. Nancy was a strong-willed individual, however, and although she wanted to go to sleep, her brain involuntarily fought against the drug. She was still audibly counting when Dr. Billing gave an additional dose of Pentothal. She said twenty-seven before the two grams of the drug succeeded in inducing sleep. Nancy Greenly fell asleep at 7:24 on February 14, 1976, for the last time.

Dr. Billing had no idea this healthy young woman was going to be his first major complication. He was confident that everything was under control The list was almost complete. He had Nancy breathe a mixture of halothane, nitrous oxide, and oxygen through a mask. Then he injected 2 cc’s of a 0.2 percent succinylcholine chloride solution into Nancy’s I.V. to effect a paralysis of all her skeletal muscles. This would make the placement of the endotracheal tube in the trachea easier. It would also allow Dr. Major to perform a bimanual exam, to rule out ovarian pathology.

The effect of the succinylcholine was seen almost immediately. At first there were minute fasciculations of the muscles of the face, then the abdomen. As the bloodstream sped the drug throughout the body, the motor and end plates of the muscles became depolarized, and total paralysis of the skeletal muscles occurred. Smooth muscles, like the heart, were unaffected, and the beep from the monitor continued without a waver.

Nancy’s tongue was paralyzed and it fell back, blocking her airway. But that didn’t matter. The muscles of the thorax and abdomen were paralyzed as well, and any attempt at breathing ceased. Although chemically different from the curare of the Amazon savages, the drug had the same effect, and Nancy would have died in five minutes. But at this point nothing was wrong. Dr. Billing was in total control. The effect was expected and desirable. Outwardly calm, inwardly very tense, Dr. Billing put down the breathing mask and reached for the laryngoscope, step number 22 on his list With the tip of the blade, he pulled the tongue forward and maneuvered past the white epiglottis, while he visualized the entrance to the trachea. The vocal cords were ajar, paralyzed with the rest of the skeletal muscles.

Swiftly Dr. Billing squirted some topical anesthetic into the trachea, followed by the endotracheal tube. The laryngoscope made a characteristic metallic snap as Dr. Billing folded the blade onto the handle. With the help of a small syringe, he inflated the cuff on the endotracheal tube, providing a seal. Quickly he attached the tip of the rubber hose, without the face mask, to the open end of the endotracheal tube. As he compressed the ventilating bag, Nancy’s chest rose in a symmetrical fashion. Dr. Billing listened to Nancy’s chest with his stethoscope and was pleased. The entubation had been as characteristically smooth as expected. He was in total control of the patient’s respiratory state. He adjusted his flow meters and set the combination of halothane, nitrous oxide, and oxygen he wanted. A few pieces of tape secured the endotracheal tube. A twist of the finger adjusted the I.V. rate. Dr. Billing’s own heart began to slow down. He never showed it, but he always got very tense during the entubation procedure. With the patient paralyzed one has to work fast, and do it right.

With a nod, Dr. Billing indicated that Gloria, D’Mateo could begin the prep of Nancy’s shaved perineum. Meanwhile Dr. Billing began to make himself comfortable for the case. His job was now reduced to close observation of the patient’s vital signs: heart rate and rhythm, blood pressure, and temperature. As long as the patient was paralyzed, he had to compress the ventilating bag, to breathe the patient The succinylcholine would wear off in eight to ten minutes; then the patient could breathe herself, and the anesthesiologist could relax. Nancy’s blood pressure stayed at 105/70. The pulse had steadily fallen from the anxiety state prior to anesthesia to a comfortable seventy-two beats per minute. Dr. Billing was happy, and he looked forward to a coffee break in about forty minutes.

The case went smoothly. Dr. Major did his bimanual examination and asked for some more relaxation. This meant that Nancy’s blood had detoxified the succinylcholine given during the entubation. Dr. Billing was happy to give another 2 cc. He dutifully recorded this in his anesthesia record. The result was immediate, and Dr. Major thanked Dr. Billing and informed the crew that the ovaries felt like little smooth, normal plums. He always said that when he felt normal ovaries. The dilation of the cervix went without a hitch. Nancy had a normally antero-flexed uterus, and the curve on the dilators was a perfect match. A few blood clots were sucked out from the vaginal vault with the suction machine. Dr. Major carefully curetted the inside of the uterus, noting the consistency of the endometrial tissue. As Dr. Major passed the second curette, Dr. Billing noted a slight change in the rhythm of the cardiac monitor. He watched the electronic blip trace across the oscilloscope screen. The pulse fell to about sixty. Instinctively he inflated the blood pressure cuff and listened intently for the familiar far-away deep sound of the blood surging through the collapsed artery. As the air pressure drained off more, he heard the rebound sound indicating the diastolic pressure. The blood pressure was 90/60. This was not terribly low, but it puzzled his analytical brain. Could Nancy be getting some vagal feedback from her uterus, he wondered. He doubted it, but just the same be took the stethoscope from his ears.

“Dr. Major, could you hold on for just a minute? The blood pressure has sagged a little. How much blood loss do you estimate?”

“Couldn’t be more than 500 cc,” said Dr. Major, looking up from between Nancy’s legs.

“That’s funny,” said Dr. Billing, replacing the stethoscope in his ears. He inflated the cuff again. Blood pressure was 90/58. He looked at the monitor: pulse sixty.

“What’s the pressure?” asked Dr. Major.

“Ninety over sixty, with a pulse of sixty,” said Dr. Billing, taking the stethoscope from his ears and rechecking the flow valves on the anesthesia machine.

“What the hell’s wrong with that, for Christ’s sake?” snapped Dr. Major, showing some early surgical irritation.

“Nothing,” agreed Dr. Billing, “but it’s a change. She had been so steady.”

“Well, her color is fantastic. Down here, she’s as red as a cherry,” said Dr. Major, laughing at his own joke. No one else laughed.

Dr. Billing looked at the clock. It was 7:48. “OK, go ahead. I’ll tell you if she changes any more,” said Dr. Billing, while giving the breathing bag a healthy squeeze to inflate Nancy’s lungs maximally. Something was bothering Dr. Billing; something was keying-off his sixth sense, activating his adrenals and pushing up his own heart rate. He watched the breathing bag sag and remain still. He compressed it again, mentally recording the degree of resistance afforded by Nancy’s bronchial tubes and lungs. She was very easy to breathe. He watched the bag again. No motion, no respiratory effect on Nancy’s part, despite the fact that the second dose of the succinylcholine should have been metabolized by then.

The blood pressure came up slightly, then went down again: 80/58. The monotonous beep of the monitor skipped once. Dr. Billing’s eyes shot to the oscilloscope screen. The rhythm picked up again.

“I’ll be finished here in five minutes,” said Dr. Major for Dr. Billing’s benefit With a sense of relief, Dr. Billing reached over and turned down both the nitrous oxide and the halothane flow, while turning up the oxygen. He wanted to lighten Nancy’s level of anesthesia. The blood pressure came up to 90/60, and Dr. Billing felt a little better. He even allowed himself the luxury of running the back of his hand across his forehead to scatter the beads of perspiration that had appeared as evidence of his increasing anxiety. He glanced at the soda-lime CO₂ absorber. It appeared normal. Time was 7:56. With his right hand he reached up and lifted Nancy’s eyelids. They moved with no resistance and the pupils were maximally dilated. The fear returned to Dr. Billing in a rush. Something was wrong… something was very wrong.